A study on correlation of coronary sinus lactate and troponin T levels with perioperative outcome in patients undergoing cardiac surgery on cardio pulmonary bypass

Myocardial ischemia is a metabolic phenomenon that occurs in patients undergoing open heart surgery like coronary artery bypass grafting (CABG), valvular heart surgery, vascular surgeries etc., due to stress imposed during cardiopulmonary bypass (CPB), obligatory interruption of coronary blood flow during aortic cross clamp and reperfusion after aortic cross clamp release. The present study is designed to have a detailed study on estimation of coronary sinus lactate and troponin t levels in patients undergoing cardiac surgery with cardiopulmonary bypass and its correlation with various parameters related to the perioperative outcomes.

Anesthetic Consideration in Case of Large Lymphangioma in Right Atrioventricular Groove: A Case Report

Background Cardiac tumor is a rare disease but it causes various hemodynamic changes depending on location and size. Compression of the right sided heart can lead to impaired venous return and consequent systemic and coronary vascular collapse. Case A 62-year-old male who had cardiac lymphangioma on right atrio-ventricular groove. Upon entering the operating room, he was admitted to the tamponade physiology with tachycardia and hypotension. Opioid based anesthesia was performed to minimize myocardial depression, and myocardial function was continuously monitored through Transesophageal echocardiography and pulmonary artery catheter to safely wean the cardio pulmonary bypass (CPB) machine. Conclusion Anesthesiologists should be able to predict and respond appropriately to physiological hemodynamic changes according to the location and size of cardiac tumor.

Oxidative stress response in children undergoing cardiac surgery: Utility of the clearance of isoprostanes

Introduction Cardiac surgery (CS) in pediatric patients induces an overt oxidative stress (OS) response. Children are particularly vulnerable to OS related injury. The immaturity of their organs and antioxidant systems as well as the induction of OS in cardio-pulmonary bypass (CPB) surgery may have an important impact on outcomes. The purpose of this study was to describe the OS response, measured by urinary free 8-iso-PGF2α, in infants undergoing CS and to evaluate the relationship between OS response and post-operative clinical outcomes. Methods Infants with congenital heart disease undergoing CS with or without CPB were eligible for enrollment. Children were classified as neonates (<30 days) or infants (30 days—6 months) based on the age at surgery. Perioperative continuous non-invasive neuromonitoring included amplitude-integrated electroencephalogram and cerebral regional oxygen saturation measured with near-infrared spectroscopy. Urine 8-iso-PGF2α levels were measured before, immediately post-, and 24-hours post-surgery, and the 8-iso-PGF2 clearance was calculated. Results Sixty-two patients (60% neonates) were included. Urine 8-iso-PGF2α levels 24 hours after surgery (8.04 [6.4–10.3] ng/mg Cr) were higher than pre-operative levels (5.7 [4.65–7.58] ng/mg Cr) (p<0.001). Those patients with a severe degree of cyanosis caused by Transposition of the Great Arteries (TGA) had the highest post-operative 8-iso-PGF2α levels. Patients with intra-operative seizures had higher post-operative 8-iso-PGF2α levels. 8-iso-PGF2α clearance at 24 hours post-surgery was different between newborns and infant patients, and it was inversely correlated with days of mechanical ventilation (p = 0.05), ICU LOS (p = 0.05) and VIS score at 24 hours (p = 0.036). Conclusions Children undergoing CS, particularly neonatal patients, experience a significant post-operative OS response that might play an important role in postoperative morbidity. TGA patients undergoing arterial switch operations demonstrate the highest post-operative OS response. Rapid clearance of isoprostanes, which occurs more frequently in older patients with more mature antioxidant systems, might be associated with better clinical outcomes.

Preoperative Serum GDF-15, Endothelin-1 Levels, and Intraoperative Factors as Short-Term Operative Risks for Patients Undergoing Cardiovascular Surgery

Objectives: The Society of Thoracic Surgeons (STS) risk score is widely used for the risk assessment of cardiac surgery. Serum biomarkers such as growth differentiation factor-15 (GDF-15) and endothelin-1 (ET-1) are also used to evaluate risk. We investigated the relationships between preoperative serum GDF-15, ET-1 levels, and intraoperative factors and short-term operative risks including acute kidney injury (AKI) for patients undergoing cardiovascular surgery. Methods: In total, 145 patients were included in this study (92 males and 53 females, age 68.4 ± 13.2 years). The preoperative STS score was determined, and the serum GDF-15 and ET-1 levels were measured by ELISA. These were related to postoperative risks, including AKI, defined according to the Acute Kidney Injury Network (AKIN) classification criteria. Results: AKI developed in 23% of patients. The GDF-15 and ET-1 levels correlated with the STS score. The STS score and GDF-15 and ET-1 levels all correlated with preoperative eGFR, Alb, Hb, and BNP levels; perioperative data (urine output); ICU stay period; and postoperative admission days. Patients with AKI had longer circulatory pulmonary bypass (CPB) time, and male patients with AKI had higher ET-1 levels than those without AKI. In multivariable logistic regression analysis, the preoperative ET-1 level and CPB time were the independent determinants of AKI, even adjusted by age, sex, and BMI. The preoperative GDF-15 level, CPB time, and RCC transfusion were independent determinants of 30-day mortality plus morbidity. Conclusion: Preoperative GDF-15 and ET-1 levels as well as intraoperative factors such as CPB time may be helpful to identify short-term operative risks for patients undergoing cardiovascular surgery.

MO413EFFECTS OF CHRONIC, LONG-TERM ACE-INHIBITOR TREATMENT ON CYTOKINE STORM AND RENAL FUNCTION AFTER CARDIO-PULMONARY BYPASS: A PROSPECTIVE OBSERVATIONAL STUDY

Background and Aims Cardiopulmonary bypass (CPB) may trigger organs damage, including kidney injury, due to a massive cytokine release. In this observational, prospective study, we have analyzed the possible impact of chronic treatment with ACE-Inhibitors (ACE-I) on the inflammatory response and renal function after CPB. Method Sixty-nine patients undergoing major cardiac surgery with CPB were enrolled. Patients were stratified according to long-term (&gt;6 mo.) ACE-I use (n=38) or not (n=31). The primary endpoint was to analyze the changes in their IL-1 alpha, IL-1beta, IL-2, IL-4, IL-6, IL-8, IL-10, TNF alpha, EGF and VEGF plasma levels. Secondary (renal) endpoints were: postoperative acute kidney injury (AKI), recovery of baseline GFR values and the absolute changes in renal function indexes. Results After CPB, IL-1alpha, IL-1beta, IL-4 and TNF-alpha remained stable overtime, while a significant decrease in IL-2 plasma levels was noticed in the ACE-I group (p=0.01). IL-6 and IL-8 plasma levels increased after surgery and tended to decrease after 48h. IL-10 plasma levels showed a similar variation, but both their rise and decrease were more pronounced in patients under ACE-I treatment (p=0.007). Finally, VEGF and EGF showed a marked initial decrease with a tendency to normalization 10 days after surgery (p for trend ranging from 0.01 to 0.001) (Figure 1-2). The occurrence of AKI within 2 days after surgery, the rate of GFR recovery and the absolute changes in renal function indexes were not statistically different between groups (Figure 3). Conclusion Chronic, long-term ACE-I treatment may influence the inflammatory response following CPB. On the other hand, this drug class apparently has neutral impact on perioperative renal outcomes.

Prognostic Value of GDF-15 in Predicting Prolonged Intensive Care Stay following Cardiac Surgery: A Retrospective Case-Control Study

Background: Predicting intensive care unit length of stay and outcome following cardiac surgery is currently based on clinical parameters. Novel biomarkers could be employed to improve the prediction models. Methods: We performed a qualitative cytokine screening array to identify highly expressed biomarkers in preoperative blood samples of cardiac surgery patients. After identification of one highly expressed biomarker, growth differentiation factor 15 (GDF-15), a quantitative ELISA was undertaken. Preoperative levels of GDF-15 were compared in regard to duration of intensive care stay, cardio-pulmonary bypass time and indicators of organ dysfunction.Results: Preoperatively, GDF-15 was highly expressed in addition to several less highly expressed other biomarkers. After qualitative analysis we could show that preoperatively raised levels of GDF-15 was positively associated with prolonged ICU stay exceeding 48 h (median 713 versus 1041 pg/ml, p = 0.003). It was also associated with prolonged mechanical ventilation and rates of severe sepsis but not with dialysis rates or cardio-pulmonary bypass time. In univariate regression, raised GDF-15 levels were predictive of a prolonged ICU stay (OR 1.01, 95% Confidence Interval 1 – 1.02, p= 0.029). On ROC curves, GDF-15 was found to predict prolonged ICU stay (AUC= 0.86, 95% Confidence Interval 0.71 – 0.99, p= 0.003).Conclusion: GDF-15 showed potential as predictor of prolonged intensive care stay following cardiac surgery, which might be valuable for risk stratification models.

Smart bracelet to assess physical activity after cardiac surgery: A prospective study

Objectives Little is known about the physical activity of patients after cardiac surgery. This study was designed to assess this activity using a connected bracelet. Methods In this prospective, monocentric study, patients scheduled for cardiac surgery were offered to wear an electronic bracelet. The main objective was to measure the physical activity recovery. Secondary objectives were the predictors of the correct use of the monitoring system, of the physical recovery and, if any, the relationship between physical activity and out-of-hospital morbidity. Results One hundred patients were included. Most patients (86%) were interested in participating in the study. The compliance to the device and to the study protocol was good (94%). At discharge, the mean number of daily steps was 1454 ± 145 steps, increasing quite homogeneously, reaching 5801±1151 steps at Day 60. The best fit regression curve gave a maximum number of steps at 5897±119 (r2 = 0.97). The 85% level of activity was achieved at Day 30±3. No predictor of noncompliance was found. At discharge, age was independently associated with a lower number of daily steps (p <0.001). At Day 60, age, peripheral arterial disease and cardio-pulmonary bypass duration were independently associated with a lower number of daily steps (p = 0.039, p = 0.041 and p = 0.033, respectively). Conclusions After cardiac surgery, wearing a smart bracelet recording daily steps is simple, well tolerated and suitable for measuring physical activity. Standard patients achieved around 6000 daily steps 2 months after discharge. 85% of this activity is reached in the first month. Clinical trial registry number NCT03113565